Feldman S E, Roblin D W
Department of Surgery, University of California at San Francisco-Mt Zion Medical Center 94120, USA.
Jt Comm J Qual Improv. 1997 Nov;23(11):567-80. doi: 10.1016/s1070-3241(16)30340-6.
Medical accidents can be understood as patient injuries that result from interaction of physician or nurse error during the provision of care with faults latent in the hospital system. Medical accidents are not random events but are events with discoverable associations between human error and system faults through application of methods of failure analysis in the evaluation of patient injuries.
The goal of a failure analysis is to make apparent system faults that are otherwise obscured. Analyses seek to answer several questions. What characteristics of the system failed to prevent a slip, mistake, or rule violation from evolving into an accident? What system changes might have offset, or prevented, the active error from contributing to the sequence of events culminating in injury? Brief descriptions of eight cases of apparent medical accidents are provided in this article. For three of these cases, the failure analysis approach is used to identify the sequence of events contributing to the patient injury; identify events within this sequence that represent active errors; and identify points within this sequence that represent system faults which failed to prevent the occurrence of subsequent events.
Within the framework of current methods of hospital quality appraisal, attribution of patient injury historically has focused on clinician error. Yet unless detected and corrected, system faults persist and create circumstances of "accidents waiting to happen." Understanding of casual factors in the evolution of medical accidents can be usefully applied toward improvement in the quality of hospital appraisal of iatrogenic injuries and, through that application, toward reduction in the rates of adverse outcomes.
医疗事故可被理解为在提供护理过程中，医生或护士的失误与医院系统中潜在的缺陷相互作用导致的患者伤害。医疗事故并非随机事件，而是通过在评估患者伤害时应用故障分析方法，能够发现人为失误与系统缺陷之间存在关联的事件。
故障分析的目的是揭示那些原本被掩盖的系统缺陷。分析旨在回答几个问题。系统的哪些特征未能防止失误、错误或违规行为演变成事故？哪些系统变更可能抵消或防止了主动失误导致最终造成伤害的一系列事件？本文提供了八起明显医疗事故的简要描述。对于其中三起案例，采用故障分析方法来确定导致患者受伤的事件序列；识别该序列中代表主动失误的事件；并识别该序列中代表未能防止后续事件发生的系统缺陷的关键点。
在当前医院质量评估方法的框架内，患者伤害的归因历来侧重于临床医生的失误。然而，除非被发现并纠正，系统缺陷将持续存在，并造成“事故随时可能发生”的情况。了解医疗事故演变过程中的偶然因素，可有效地应用于改善医院对医源性伤害的评估质量，并通过这种应用降低不良后果的发生率。
